Amoebiasis

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This article is about the infection. For the Amoebic Ensemble album, see Amoebiasis
(album).
Amoebiasis
Classification and external resources
ICD-10 A06.
ICD-9 006
MeSH D000562

Life-cycle of the Entamoeba histolytica

Amoebiasis, or Amebiasis refers to infection caused by the amoeba Entamoeba

histolytica.[1][2] The term Entamoebiasis is occasionally seen but is no longer in use;[citation
needed]
it refers to the same infection. Likewise amoebiasis is sometimes incorrectly used
to refer to infection with other amoebae, but strictly speaking it should be reserved for
Entamoeba histolytica infection. Other amoebae infecting humans include:

• Parasites
 o Dientamoeba fragilis, which causes Dientamoebiasis
o Entamoeba dispar
o Entamoeba hartmanni
o Entamoeba coli
o Entamoeba moshkovskii
o Endolimax nana and
o Iodamoeba butschlii.

Except for Dientamoeba, the parasites above are not thought to cause disease.

• Free living amoebas[3][4]. These species are often described as "opportunistic

free-living amoebas" as human infection is not an obligate part of their life cycle.
o Naegleria fowleri, which causes Primary amoebic meningoencephalitis
o Acanthamoeba, which causes Cutaneous amoebiasis[5] and
Acanthamoeba keratitis
o Balamuthia mandrillaris,[6] which causes Granulomatous amoebic
encephalitis and Primary amoebic meningoencephalitis
o Sappinia diploidea

A gastrointestinal infection that may or may not be symptomatic and can remain latent
in an infected person for several years, amoebiasis is estimated to cause 70,000 deaths
per year world wide.[7] Symptoms can range from mild diarrhea to dysentery with blood
and mucus in the stool. E. histolytica is usually a commensal organism.[8] Severe
amoebiasis infections (known as invasive or fulminant amoebiasis) occur in two major
forms. Invasion of the intestinal lining causes amoebic dysentery or amoebic colitis. If
the parasite reaches the bloodstream it can spread through the body, most frequently
ending up in the liver where it causes amoebic liver abscesses. Liver abscesses can
occur without previous development of amoebic dysentery. When no symptoms are
present, the infected individual is still a carrier, able to spread the parasite to others
through poor hygienic practices. While symptoms at onset can be similar to bacillary
dysentery, amoebiasis is not bacteriological in origin and treatments differ, although
both infections can be prevented by good sanitary practices.

Transmission

Amoebiasis is usually transmitted by the fecal-oral route, but it can also be transmitted
indirectly through contact with dirty hands or objects as well as by anal-oral contact.
Infection is spread through ingestion of the cyst form of the parasite, a semi-dormant
and hardy structure found in feces. Any non-encysted amoebae, or trophozoites, die
quickly after leaving the body but may also be present in stool: these are rarely the
source of new infections. Since amoebiasis is transmitted through contaminated food
and water, it is often endemic in regions of the world with limited modern sanitation
systems, including México, Central America, western South America, South Asia, and
western and southern Africa.[9]
Amoebic dysentery is often confused with "traveler's diarrhea" because of its prevalence
in developing nations. In fact, most traveler's diarrhea is bacterial or viral in origin.

Prevention

To help prevent the spread of amoebiasis around the home :

• Wash hands thoroughly with soap and hot running water for at least 10 seconds
after using the toilet or changing a baby's diaper, and before handling food.
• Clean bathrooms and toilets often; pay particular attention to toilet seats and
taps.
• Avoid sharing towels or face washers.

To help prevent infection:

• Avoid raw vegetables when in endemic areas, as they may have been fertilized
using human feces.
• Boil water or treat with iodine tablets.

Nature of the disease

Most infected people, perhaps 90%, are asymptomatic, but this disease has the
potential to make the sufferer dangerously ill. It is estimated by the World Health
Organization that about 70,000 people die due to amoebiasis annually worldwide.

Infections can sometimes last for years. Symptoms take from a few days to a few weeks
to develop and manifest themselves, but usually it is about two to four weeks.
Symptoms can range from mild diarrhoea to dysentery with blood and mucus. The
blood comes from amoebae invading the lining of the intestine. In about 10% of invasive
cases the amoebae enter the bloodstream and may travel to other organs in the body.
Most commonly this means the liver, as this is where blood from the intestine reaches
first, but they can end up almost anywhere.

Onset time is highly variable and the average asymptomatic infection persists for over a
year. It is theorised that the absence of symptoms or their intensity may vary with such
factors as strain of amoeba, immune response of the host, and perhaps associated
bacteria and viruses.

In asymptomatic infections the amoeba lives by eating and digesting bacteria and food
particles in the gut, a part of the gastrointestinal tract.[citation needed] It does not usually come
in contact with the intestine itself due to the protective layer of mucus that lines the gut.
Disease occurs when amoeba comes in contact with the cells lining the intestine. It then
secretes the same substances it uses to digest bacteria, which include enzymes that
destroy cell membranes and proteins. This process can lead to penetration and
digestion of human tissues, resulting first in flask-shaped ulcers in the intestine.
Entamoeba histolytica ingests the destroyed cells by phagocytosis and is often seen
with red blood cells inside when viewed in stool samples. Especially in Latin America,
[citation needed]
a granulomatous mass (known as an amoeboma) may form in the wall of the
ascending colon or rectum due to long-lasting immunological cellular response, and is
sometimes confused with cancer.[10]

"Theoretically, the ingestion of one viable cyst can cause an infection."[11]

Diagnosis of human illness

Immature E. histolytica/E. dispar cyst in a concentrated wet mount stained with iodine.
This early cyst has only one nucleus and a glycogen mass is visible (brown stain). From
CDC’s Division of Parasitic Diseases

Asymptomatic human infections are usually diagnosed by finding cysts shed in the
stool. Various flotation or sedimentation procedures have been developed to recover
the cysts from fecal matter and stains help to visualize the isolated cysts for microscopic
examination. Since cysts are not shed constantly, a minimum of three stools should be
examined. In symptomatic infections, the motile form (the trophozoite) can often be
seen in fresh feces. Serological tests exist and most individuals (whether with
symptoms or not) will test positive for the presence of antibodies. The levels of antibody
are much higher in individuals with liver abscesses. Serology only becomes positive
about two weeks after infection. More recent developments include a kit that detects the
presence of amoeba proteins in the feces and another that detects ameba DNA in
feces. These tests are not in widespread use due to their expense.
Amoebic dysentery in colon biopsy.

Microscopy is still by far the most widespread method of diagnosis around the world.
However it is not as sensitive or accurate in diagnosis as the other tests available. It is
important to distinguish the E. histolytica cyst from the cysts of nonpathogenic intestinal
protozoa such as Entamoeba coli by its appearance. E. histolytica cysts have a
maximum of four nuclei, while the commensal Entamoeba coli cyst has up to 8 nuclei.
Additionally, in E. histolytica, the endosome is centrally located in the nucleus, while it is
usually off-center in Entamoeba coli. Finally, chromatoidal bodies in E. histolytica cysts
are rounded, while they are jagged in Entamoeba coli. However, other species,
Entamoeba dispar and E. moshkovskii, are also commensals and cannot be
distinguished from E. histolytica under the microscope. As E. dispar is much more
common than E. histolytica in most parts of the world this means that there is a lot of
incorrect diagnosis of E. histolytica infection taking place. The WHO recommends that
infections diagnosed by microscopy alone should not be treated if they are
asymptomatic and there is no other reason to suspect that the infection is actually E.
histolytica.

Typically, the organism can no longer be found in the feces once the disease goes
extra-intestinal.[citation needed] Serological tests are useful in detecting infection by E.
histolytica if the organism goes extra-intestinal and in excluding the organism from the
diagnosis of other disorders. An Ova & Parasite (O&P) test or an E. histolytica fecal
antigen assay is the proper assay for intestinal infections. Since antibodies may persist
for years after clinical cure, a positive serological result may not necessarily indicate an
active infection. A negative serological result however can be equally important in
excluding suspected tissue invasion by E. histolytica.[citation needed]

Relative frequency of the disease

In older textbooks it is often stated that 10% of the world's population is infected with
Entamoeba histolytica.[citation needed] It is now known that at least 90% of these infections
are due to E. dispar. Nevertheless, this means that there are up to 50 million true E.
histolytica infections and approximately seventy thousand die each year, mostly from
liver abscesses or other complications. Although usually considered a tropical parasite,
the first case reported (in 1875) was actually in St Petersburg in Russia, near the Arctic
Circle.[12] Infection is more common in warmer areas, but this is both because of poorer
hygiene and the parasitic cysts surviving longer in warm moist conditions.[9]

Treatment

E. histolytica infections occur in both the intestine and (in people with symptoms) in
tissue of the intestine and/or liver.[9] As a result, two different classes of drugs are
needed to treat the infection, one for each location. Such anti-amoebic drugs are known
as amoebicides or amebicides.
Both tissue and lumenal drugs must be used to treat infections, with Metronidazole
usually being given first, followed by Paromomycin or Diloxanide.

E. dispar does not require treatment, but many laboratories (even in the developed
world) do not have the facilities to distinguish this from E. histolytica.

Tissue amebicides

Metronidazole, or a related drug such as Tinidazole, Secnidazole or Ornidazole, is used

to destroy amoebae that have invaded tissue.[9] These are rapidly absorbed into the
bloodstream and transported to the site of infection. Because they are rapidly absorbed
there is almost none remaining in the intestine.

For amebic dysentery a multi-prong approach must be used, starting with one of:

• Metronidazole 500-750 mg three times a day for 5-10 days

• Tinidazole 2g once a day for 3 days is an alternative to metronidazole

Doses for children are calculated by body weight and a pharmacist should be consulted
for help.

Luminal amebicides

Since most of the amoebae remain in the intestine when tissue invasion occurs, it is
important to get rid of those also or the patient will be at risk of developing another case
of invasive disease. Several drugs are available for treating intestinal infections, the
most effective of which has been shown to be Paromomycin (also known as Humatin);
Diloxanide furoate (also known as Furamide) is used in the US and Iodoquinol (also
known as Yodoxin) is used in certain other countries.

In addition to the tissue amebicides above, one of the following luminal amebicides
should be prescribed as an adjunctive treatment, either concurrently or sequentially, to
destroy E. histolytica in the colon:

• Paromomycin 500 mg three times a day for 10 days

• Diloxanide furoate 500 mg three times a day for 10 days
• Iodoquinol 650 mg three times a day for 20 days

Doses for children are calculated by body weight and a pharmacist should be consulted
for help.

For amebic liver abscess

For amebic liver abscess:

• Metronidazole 400 mg three times a day for 10 days

 • Tinidazole 2g once a day for 6 days is an alternative to metronidazole
• Diloxanide furoate 500 mg three times a day for 10 days (or one of the other
lumenal amebicides above) must always be given afterwards

Doses for children are calculated by body weight and a pharmacist should be consulted
for help.

Complications

In the majority of cases, amoebas remain in the gastrointestinal tract of the hosts.
Severe ulceration of the gastrointestinal mucosal surfaces occurs in less than 16% of
cases. In fewer cases, the parasite invades the soft tissues, most commonly the liver.
Only rarely are masses formed (amoebomas) that lead to intestinal obstruction.

Entamoeba histolytica infection is associated with malnutrition and stunting of growth.[13]

Food analysis

E. histolytica cysts may be recovered from contaminated food by methods similar to

those used for recovering Giardia lamblia cysts from feces. Filtration is probably the
most practical method for recovery from drinking water and liquid foods. E. histolytica
cysts must be distinguished from cysts of other parasitic (but nonpathogenic) protozoa
and from cysts of free-living protozoa as discussed above. Recovery procedures are not
very accurate; cysts are easily lost or damaged beyond recognition, which leads to
many falsely negative results in recovery tests.[14]

Outbreaks

The most dramatic incident in the USA was the Chicago World's Fair outbreak in 1933
caused by contaminated drinking water; defective plumbing permitted sewage to
contaminate water.[15] There were 1,000 cases (with 58 deaths). In 1998 there was an
outbreak of amoebiasis in the Republic of Georgia.[16] One hundred and seventy-seven
cases were reported between 26 May and 3 September 1998, including 71 cases of
intestinal amoebiasis and 106 probable cases of liver abscess.

Amoebiasis Symptoms and Treatments Amoebiasis is an infection in the bowel,

particularly the colon, characterized by diarrhea. This infection can be fatal in infant and
to older people with low resistance. The main risk is due to dehydration from the loss of
fluid.
Amoebas

Symptoms of Amoebiasis :

• Abdominal pain with an urge to go to the bathroom frequently.

• Fever and diarrhea which frequently accompanied with blood and/or mucous
discharge.
• Sometimes diarrhea alternates with bouts of constipation, with one occurring for
several days, followed by the other.
• When diarrhea becomes yellow containing neither mucous nor blood but is
foamy, this is known as Giardia, an illness brought on by different type of
microscopic parasite. When you have fever and bloody diarrhea, the infection is
not caused by amoebas, but by bacteria and it is called Shigella.

Causes of Amoebiasis :

• Both the bacterial and amoebic form of dysentery are usually spread by food or
water that is contaminated with fecal matter of infected individual.
• Tropical climate favors the spread of disease because of the abundance of
insects that act as carriers of the disease causing organisms.

Recommended Treatment for Amoebiasis :

• Take generous amount of Garlic and Bee propolis for 10 to 15 days, or more if
necessary. Garlic and Bee propolis are both potent natural antibiotic.
• Drink lots of fluid or hydrating liquid.

If you suffer from Shigella and other bacterial infections, the same treatment is
recommended.

Sometimes amoebas can pass into the liver and cause hepatic abscesses(forming
pockets of pus), which manifest themselves through pain on the right side of the
stomach or chest. It also causes pain when walking. Consult your doctor.
Amoebiasis / Amoebic Dysentery : Definition, Types, Causes, Symptoms,
Diagnosis and general treatment of Amoebiasis/ Amoebic Dysentery

Amoebiasis is a common infection of the human gastrointestinal tract. It has a world

wide distribution. It is.a major health problem in the whole of Chi,na, South East and
West Asia and Latin America, especially Mexico. Globally it was estimated that, in 1981,
480 million people carried E. histolytica in their intestinal tract and approximately one-
tenth of infected people, i.e., 48 million suffered from invasive amoebiasis. It is probable
that invasive amoebiasis, accounts annually for 40,000 to 110,000 deaths in the world
(3). Prevalence rates vary from as low as 2 per cent to 60 per cent or more in areas
devoid of sanitation (4). In areas of high prevalance. Amoebiasis occurs in endemic
forms as a result of high levels of transmission and constant reinfection. Epidemic
water-born infections can occur if there is heavy contamination of drinking water supply.

Amoebiasis, a type of gastro, is a cause of diarrhoea among travellers to developing

countries. It is caused by a parasite known as Entamoeba histolytica that infects the
bowel. Amoebiasis is a parasitic infection of the large intestine. Amoebiasis can affect
anyone, most commonly affects young to middle-aged adults. The term "amoebiasis"
has been defined as the condition of harbouring the protozoan parasite Entamoeba
histolytica with or without clinical manifestations. The symptomatic disease occurs in
less than 10 per cent of infected individuals.

The symptomatic group has been further subdivided into intestinal and extraintestinal
amoebiasis. Only a small percentage of those having intestinal infection will develop
invasive amoebiasis. The intestinal disease varies from mild abdominal discomfort and
diarrhoea to acute fulminating dysentery. Extraintestinal amoebiasis includes
involvement of liver (liver abscess), Iungs, brain, spleen, skin, etc. Amoebiasis is a
potentially lethal disease. It carries substantial morbidity and mortality. It is the simplest
organism of the animal kingdom which belongs to the class of Rhizopoda, order of
Amoebida, genus of Entamoeba and species of E.Histolytica.

Causes of Amoebiasis

Amoebiasis is causes by a parasite that can live in humans without making them ill, or it
can make a person very sick by going into organs like the liver or heart.

The parasite only lives in humans, and can be spread from person to person. People
can get the disease by eating food, or drinking water that contain the parasite. A person
may also spread the disease by not washing their hands after going to the toilet or
changing a nappy, and then handling food for other people.

Amoebiasis is caused by potentially pathogenic strains of E. histolytica. Recent studies

have shown that E. histolytica can be differentiated into at least 18 zymodemes (a
zymodeme is a population of organisms differing from similar populations in the
electrophoretic mobilities of one or more enzymes). It has furthermore been shown that
pathogenic strains are all from particular zymodemes; that non, invasive strains are
from quite distinct zymodemes; that invasive strains can give rise to faecal cysts, and
the organisms breed true . The iso-enzyme characteristics do not, however, determine
why a particular zymodeme is able to invade. Isoenzyme electrophoretic mobility
analysis have so far identified 7 potentially pathogenic and 11 non-pathogenic
zymodems.

Forms of Amoebasis / Amoebic Dysentery

E. histolytica exists in two forms - vegetative (trophozoite) and cystic forms.

Trophozoites dwell in the colon where they multiply and encyst. The cysts are excreted
in stool. Ingested cysts release trophozoites which colonize the large intestine. Some
trophozoites invade the bowel and cause ulceration, mainly in the caecum and
ascending colon; than in the rectum and sigmoid. Some may enter a vein and reach the
liver and other organs.

The trophozoites are short-lived outside the human body; they are not important in the
transmission of the disease. In contrast the cysts are infective to man and remain viable
and infective for several days in faeces, water, sewage and soil in the presence of
moisture and low temperature. The cysts are not affected by chlorine in the amounts
normally used in water purification, but they are readily killed if dried, heated (to about'
55 deg C) or frozen.

How its spread

Amoebiasis may occur at any age. There is no sex or racial difference in the occurrence
of the disease. Amoebiasis is frequently a household infection. When an individual in a
family is infected, others in the family may a Iso be affected. Specific a ntiamoebic
antibodies are produced when tissue invasion takes place. There is strong evidence
that cell-mediated immunity plays an important part in controlling the recurrence of
invasive amoebiasis . Amoebiasis occurs when the parasites are taken in by mouth.
People with amoebiasis have Entamoeba hisolytica parasites in their faeces. The
infection can spread when infected people do not dispose of their faeces in a sanitary
manner or do not wash their hands properly after going to the toilet. Contaminated
hands can then spread the parasites to food that may be eaten by other people and
surfaces that may be touched by other people. Hands can also become contaminated
when changing the nappies of an infected infant. Amoebiasis can also be spread by:

Faecal-oral route. This may readily take place through intake of contaminated water or
food. Epidemic water-borne infections can occur if there is heavy contamination of
drinking water supply. Vegetables, especially those eaten raw, from fields irrigated with
sewage polluted water can readily convey infection. Viable cysts have been found on
the hands.and under finger nails. This may lead to direct hand to mouth transmission.

Sexual transmission by oral-rectal contact is also recognized, especially among male

homosexuals. (Hi) Vectors such as flies, cockroaches and rodents are capable of
carrying cysts and contaminating food and drink.
Symptoms of Amoebiasis / Amoebic Dysentery

Most of the cases may not have any symptoms at all and function only as carriers and
also function as spreaders, polluting the areas wherever they go. The disease
symptoms usually start after a period of 7-15 days of infection which is called the
incubation period. The symptoms are in two forms:

1. By burrowing the intestines and making ulcers, which bleed and cause anaemia or
other diseases due to added infection
2. Absorbing the food from the host or letting out toxic substances in the intestines

Usually symptoms start with diarrhoea (watery stools) and abdominal pain (mostly in
right hypochondrium)

Poor appetite or fear of food due to abdominal pain and loose stools

Later, with increased intensity of the infection, fever, nausea and bloody stools i.e.
characteristic amoebic dysentery with slimy mucous occurs and complicate the
condition

In due course, the patient loses weight and stamina

Sometimes allergic reactions can occur throughout the body, due to release of toxic
substances or dead parasites inside the intestines.

Diagnosis of Amoebiasis / Amoebic Dysentery

Stool examination - Microscopic examination for identifying demonstrable E.H cysts or

trophozoites in stool samples is the most confirmative method for diagnosis.
Trophozoites survive only for a few hours, so the diagnosis mostly goes with the
presence of cysts. But fresh warm faeces always show trophozoites. The cysts are
identified by their spherical nature with chromatin bars and nucleus. They are noticed as
brownish eggs when stained with iodine.
Biopsy also can point out E.H cysts or trophozoites.
Culture of the stool also can guide us for diagnosis.
Blood tests may suggest infection which may be indicated as leucocytosis (increased
level of white blood cells), also it can indicate whether any damage to the liver has
occurred or not.
Ultrasound scan - it should be performed when a liver abscess is suspected.

Treatment of Amoebiasis / Amoebic Dysentery

Symptomatic cases: At the health centre level, symptomatic cases can be treated
effectively with metronidazole orally and the clinical response in 48 hours may confirm
the suspected diagnosis. The dose is 30mg/kg/day, divided into 3 doses after meals, for
8-10 days. Tinidazole can be used instead of metronidazole. Suspected cases of liver
abscess should be referred to the nearest hospital. (ii) Asymptomatic infections: In an
endemic area, the concensus is not to treat such persons because the probability of
reinfection is very high (3). They may however be treated, if the carrie is a food handler.
In non-endemic areas they are always likely to h treated. They should be treated with
oral diiodohyroxyquin, 650 ml t.d.s. (adults) or 30-40 mg/kg/day (children) for 20 days,
or ore diloxanide furoate, 500 mg t.d.s. for 10 days (adults).

At present there is no acceptable chemoprophylaxis for amoebiasis. Mass examination

and treatment cannot be considered solution for the control of amoebiasis.